Detection of dysplasia in Barrett's esophagus with in vivo depth-resolved nuclear morphology measurements

Recovery of angular scattering profiles through a flexible multimode fiber

Endoscopic angle-resolved light scattering methods have been developed for early cancer detection but they typically require multi-element coherent fiber optic bundles to recover scattering distributions from tissues. Recent work has focused on using a single multimode fiber (MMF) to measure angle resolved scattering but this approach has practical limitations to overcome before clinical translation. Here we address these limitations by proposing an MMF-based endoscope capable of measuring angular scattering patterns suitable for determining structure. Significantly, this approach implements a spectrally resolved detection scheme to reduce speckle and leverages the azimuthal symmetry of the angular scattering patterns to enable measurements that are robust to fiber bending. This results in a unique method that does not require matrix inversion or machine learning to measure a transmitted scattering distribution. The MMF utilized here is 1000 mm in length with a 200 µm core and is demonstrated to recover angular scattering distributions even with bending displacements of up to 30 cm. This advance has a significant impact on the clinical translation of biomedical endoscopic diagnostic techniques that use angular scattering to determine the size of cell nuclei to detect early cancer.

Next-generation endoscopic probe for detection of esophageal dysplasia using combined OCT and angle-resolved low-coherence interferometry

Angle-resolved low-coherence interferometry (a/LCI) is an optical technique that enables depth-specific measurements of nuclear morphology, with applications to detecting epithelial cancers in various organs. Previous a/LCI setups have been limited by costly fiber-optic components and large footprints. Here, we present a novel a/LCI instrument incorporating a channel for optical coherence tomography (OCT) to provide real-time image guidance. We showcase the system's capabilities by acquiring imaging data from in vivo Barrett's esophagus patients. The main innovation in this geometry lies in implementing a pathlength-matched single-mode fiber array, offering substantial cost savings while preserving signal fidelity. A further innovation is the introduction of a specialized side-viewing probe tailored for esophageal imaging, featuring miniature optics housed in a custom 3D-printed enclosure attached to the tip of the endoscope. The integration of OCT guidance enhances the precision of tissue targeting by providing real-time morphology imaging. This novel device represents a significant advancement in clinical translation of an enhanced screening approach for esophageal precancer, paving the way for more effective early-stage detection and intervention strategies.

Esophageal OCT Imaging Using a Paddle Probe Externally Attached to Endoscope

BACKGROUND AND AIMS

Endoscopic surveillance of Barrett's esophagus (BE) by white light examination is insufficient to diagnose dysplastic change. In this work, we describe an optical imaging method to obtain high-resolution cross-sectional imaging using a paddle-shaped probe affixed to the endoscope tip.

METHODS

We integrated Optical Coherence Tomography (OCT), an optical imaging method that produces cross-sectional images, into a paddle probe attached to video endoscope. We acquired images of esophageal epithelium from patients undergoing routine upper GI endoscopy. Images were classified by a reviewer blinded to patient identity and condition, and these results were compared with clinical diagnosis.

RESULTS

We successfully captured epithelial OCT images from 30 patients and identified features consistent with both squamous epithelium and Barrett's esophagus. Our blinded image reviewer classified BE versus non-BE with 91.5% accuracy (65/71 image regions), including sensitivity of 84.6% for BE (11/13) and a specificity of 93.1% (54/58). However, in 16 patients, intubation of the probe into the esophagus could not be achieved.

CONCLUSIONS

A paddle probe is a feasible imaging format for acquiring cross-sectional OCT images from the esophagus and can provide a structural assessment of BE and non-BE tissue. Probe form factor is the current limiting obstacle, but could be addressed by further miniaturization.

First-in-human pilot study of snapshot multispectral endoscopy for early detection of Barrett's-related neoplasia

SIGNIFICANCE

The early detection of dysplasia in patients with Barrett's esophagus could improve outcomes by enabling curative intervention; however, dysplasia is often inconspicuous using conventional white-light endoscopy.

AIM

We sought to determine whether multispectral imaging (MSI) could be applied in endoscopy to improve detection of dysplasia in the upper gastrointestinal (GI) tract.

APPROACH

We used a commercial fiberscope to relay imaging data from within the upper GI tract to a snapshot MSI camera capable of collecting data from nine spectral bands. The system was deployed in a pilot clinical study of 20 patients (ClinicalTrials.gov NCT03388047) to capture 727 in vivo image cubes matched with gold-standard diagnosis from histopathology. We compared the performance of seven learning-based methods for data classification, including linear discriminant analysis, k-nearest neighbor classification, and a neural network.

RESULTS

Validation of our approach using a Macbeth color chart achieved an image-based classification accuracy of 96.5%. Although our patient cohort showed significant intra- and interpatient variance, we were able to resolve disease-specific contributions to the recorded MSI data. In classification, a combined principal component analysis and k-nearest-neighbor approach performed best, achieving accuracies of 95.8%, 90.7%, and 76.1%, respectively, for squamous, non-dysplastic Barrett's esophagus and neoplasia based on majority decisions per-image.

CONCLUSIONS

MSI shows promise for disease classification in Barrett's esophagus and merits further investigation as a tool in high-definition "chip-on-tip" endoscopes.

Deep learning classification of cervical dysplasia using depth-resolved angular light scattering profiles

We present a machine learning method for detecting and staging cervical dysplastic tissue using light scattering data based on a convolutional neural network (CNN) architecture. Depth-resolved angular scattering measurements from two clinical trials were used to generate independent training and validation sets as input of our model. We report 90.3% sensitivity, 85.7% specificity, and 87.5% accuracy in classifying cervical dysplasia, showing the uniformity of classification of a/LCI scans across different instruments. Further, our deep learning approach significantly improved processing speeds over the traditional Mie theory inverse light scattering analysis (ILSA) method, with a hundredfold reduction in processing time, offering a promising approach for a/LCI in the clinic for assessing cervical dysplasia.

Two-photon polymerization nanofabrication of ultracompact light scattering spectroscopic probe for detection of pre-cancer in pancreatic cyst

Pancreatic cancer has one of the worst survival rates of all major cancers, with pancreatic cystic lesions accounting for one in three pancreatic surgeries. The current gold-standard for diagnosis of pancreatic cyst malignancy is based on the endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) procedure, which suffers from a low accuracy in detecting malignancy. Here we present the design and two-photon polymerization based fabrication of refractive and reflective non-contact probes, capable of rapid surveillance of the entire internal cyst surface-an advance over the contact probe we recently developed that allowed, for the first time, reliable evaluation of pancreatic cyst malignant potential in vivo. We employed a novel two-photon polymerization technique, which allows direct laser-writing to an accuracy of tens of nanometers, to fit the probe within the 540 micrometer internal diameter EUS-FNA needle. The newly constructed probes show excellent separation of the illumination and collection beams, essential for proper operation of the spatial gating method. These probes can be used clinically to perform rapid "optical biopsy", ultimately eliminating unnecessary pancreatic surgeries on benign cysts and dangerous delays in surgical removal of malignant cysts, improving patient prognosis and quality of life.

Assessment of internal refractive index profile of stochastically inhomogeneous nuclear models via analysis of two-dimensional optical scattering patterns

SIGNIFICANCE

Optical scattering signals obtained from tissue constituents contain a wealth of structural information. Conventional intensity features, however, are mostly dictated by the overall morphology and mean refractive index of these constituents, making it very difficult to exclusively sense internal refractive index fluctuations.

AIM

We perform a systematic analysis to elucidate how changes in internal refractive index profile of cell nuclei can best be detected via optical scattering.

APPROACH

We construct stochastically inhomogeneous nuclear models and numerically simulate their azimuth-resolved scattering patterns. We then process these two-dimensional patterns with the goal of identifying features that directly point to subnuclear structure.

RESULTS

Azimuth-dependent intensity variations over the side scattering range provide significant insights into subnuclear refractive index profile. A particular feature we refer to as contrast ratio is observed to be highly sensitive to the length scale and extent of refractive index fluctuations; further, this feature is not susceptible to changes in the overall size and mean refractive index of nuclei, thereby allowing for selective tracking of subnuclear structure that can be linked to chromatin distribution.

CONCLUSIONS

Our analysis will potentially pave the way for scattering-based assessment of chromatin reorganization that is considered to be a key hallmark of precancer progression.

Novel endoscopic optical diagnostic technologies in medical trial research: recent advancements and future prospects

Novel endoscopic biophotonic diagnostic technologies have the potential to non-invasively detect the interior of a hollow organ or cavity of the human body with subcellular resolution or to obtain biochemical information about tissue in real time. With the capability to visualize or analyze the diagnostic target in vivo, these techniques gradually developed as potential candidates to challenge histopathology which remains the gold standard for diagnosis. Consequently, many innovative endoscopic diagnostic techniques have succeeded in detection, characterization, and confirmation: the three critical steps for routine endoscopic diagnosis. In this review, we mainly summarize researches on emerging endoscopic optical diagnostic techniques, with emphasis on recent advances. We also introduce the fundamental principles and the development of those techniques and compare their characteristics. Especially, we shed light on the merit of novel endoscopic imaging technologies in medical research. For example, hyperspectral imaging and Raman spectroscopy provide direct molecular information, while optical coherence tomography and multi-photo endomicroscopy offer a more extensive detection range and excellent spatial-temporal resolution. Furthermore, we summarize the unexplored application fields of these endoscopic optical techniques in major hospital departments for biomedical researchers. Finally, we provide a brief overview of the future perspectives, as well as bottlenecks of those endoscopic optical diagnostic technologies. We believe all these efforts will enrich the diagnostic toolbox for endoscopists, enhance diagnostic efficiency, and reduce the rate of missed diagnosis and misdiagnosis.

Advanced endoscopic imaging for detecting and guiding therapy of early neoplasias of the esophagus

Esophageal cancers, largely adenocarcinoma in Western countries and squamous cell cancer in Asia, present a significant burden of disease and remain one of the most lethal of cancers. Key to improving survival is the development and adoption of new imaging modalities to identify early neoplastic lesions, which may be small, multifocal, subsurface, and difficult to detect by standard endoscopy. Such advanced imaging is particularly relevant with the emergence of ablative techniques that often require multiple endoscopic sessions and may be complicated by bleeding, pain, strictures, and recurrences. Assessing the specific location, depth of involvement, and features correlated with neoplastic progression or incomplete treatment may optimize treatments. While not comprehensive of all endoscopic imaging modalities, we review here some of the recent advances in endoscopic luminal imaging, particularly with surface contrast enhancement using virtual chromoendoscopy, highly magnified subsurface imaging with confocal endomicroscopy, optical coherence tomography, elastic scattering spectroscopy, angle-resolved low-coherence interferometry, and light scattering spectroscopy. While there is no single ideal imaging modality, various multimodal instruments are also being investigated. The future of combining computer-aided assessments, molecular markers, and improved imaging technologies to help localize and ablate early neoplastic lesions shed hope for improved disease outcome.

Prospective detection of cervical dysplasia with scanning angle-resolved low coherence interferometry

We present a prospective clinical study using angle-resolved low-coherence interferometry (a/LCI) to detect cervical dysplasia via depth resolved nuclear morphology measurements. The study, performed at the Jacobi Medical Center, compares 80 a/LCI optical biopsies taken from 20 women with histopathological tissue diagnosis of co-registered physical biopsies. A novel instrument was used for this study that enables 2D scanning across the cervix without repositioning the probe. The main study goal was to compare performance with a previous clinical a/LCI point-probe instrument [Int. J. Cancer140, 1447 (2017)] and use the same diagnostic criteria as in that study. Tissue was classified in two schemes: non-dysplastic vs. dysplastic and low-risk vs. high-risk, with the latter classification aligned with clinically actionable diagnosis. High sensitivity (non-dysplastic vs. dysplastic: 0.903, low-risk vs. high-risk: 1.000) and NPV (0.930 and 1.000 respectively) were obtained when using the previously established decision boundaries, showing the success of the scanning a/LCI instrument and reinforcing the clinical viability of a/LCI in disease detection.

Spatial scanning of a sample with two-dimensional angle-resolved low-coherence interferometry for analysis of anisotropic scatterers

Angle-resolved low-coherence interferometry (a/LCI) measures depth-resolved angular scattering for cell nuclear morphology analysis. 2D a/LCI, developed to collect across two scattering planes, is currently limited by the lack of spatial scanning. Here we demonstrate 2D a/LCI scanning across a three-dimensional volume using an image rotation scheme and a scanning mirror. Validation using various optical phantoms demonstrated excellent scatterer size determination over a 7.5 mm linear range, for a total accessible area of ∼44 mm². Measurements from anisotropic scatterers allowed accurate determination of sizes and computation of aspect ratios. This scanning system will facilitate analysis of scatterer structure across wider tissue areas.

Reconstruction of angle-resolved backscattering through a multimode fiber for cell nuclei and particle size determination

We demonstrate reconstruction of angle-resolved optical backscattering after transmission through a multimode fiber. Angle-resolved backscattering is an important tool for particle sizing, and has been developed as a diagnostic modality for detecting epithelial precancer. In this work, we fully characterized the transfer function of a multimode fiber using a plane-wave illumination basis across two dimensions. Once characterized, angle-resolved scattering information which has been scrambled by multimodal propagation can be easily and accurately reconstructed. Our technique was validated using a Mie theory-based inverse light scattering analysis (ILSA) algorithm on polystyrene microsphere phantoms of known sizes. To demonstrate the clinical potential of this approach, nuclear morphology was determined from the reconstructed angular backscattering from MCF-10A human mammary epithelial cell samples and validated against quantitative image analysis (QIA) of fluorescence microscopy images.

Multimodal Coherent Imaging of Retinal Biomarkers of Alzheimer's Disease in a Mouse Model

We acquired depth-resolved light scattering measurements from the retinas of triple transgenic Alzheimer’s Disease (3xTg-AD) mice and wild type (WT) age-matched controls using co-registered angle-resolved low-coherence interferometry (a/LCI) and optical coherence tomography (OCT). Angle-resolved light scattering measurements were acquired from the nerve fiber layer, outer plexiform layer, and retinal pigmented epithelium using image guidance and segmented thicknesses provided by co-registered OCT B-scans. Analysis of the OCT images showed a statistically significant thinning of the nerve fiber layer in AD mouse retinas compared to WT controls. The a/LCI scattering measurements provided complementary information that distinguishes AD mice by quantitatively characterizing tissue heterogeneity. The AD mouse retinas demonstrated higher mean and variance in nerve fiber layer light scattering intensity compared to WT controls. Further, the difference in tissue heterogeneity was observed through short-range spatial correlations that show greater slopes at all layers of interest for AD mouse retinas compared to WT controls. A greater slope indicates a faster loss of spatial correlation, suggesting a loss of tissue self-similarity characteristic of heterogeneity consistent with AD pathology. Use of this combined modality introduces unique tissue texture characterization to complement development of future AD biomarker analysis.

Quantitative phase and polarization imaging through an optical fiber applied to detection of early esophageal tumorigenesis

Phase and polarization of coherent light are highly perturbed by interaction with microstructural changes in premalignant tissue, holding promise for label-free detection of early tumors in endoscopically accessible tissues such as the gastrointestinal tract. Flexible optical multicore fiber (MCF) bundles used in conventional diagnostic endoscopy and endomicroscopy scramble phase and polarization, restricting clinicians instead to low-contrast amplitude-only imaging. We apply a transmission matrix characterization approach to produce full-field en-face images of amplitude, quantitative phase, and resolved polarimetric properties through an MCF. We first demonstrate imaging and quantification of biologically relevant amounts of optical scattering and birefringence in tissue-mimicking phantoms. We present an entropy metric that enables imaging of phase heterogeneity, indicative of disordered tissue microstructure associated with early tumors. Finally, we demonstrate that the spatial distribution of phase and polarization information enables label-free visualization of early tumors in esophageal mouse tissues, which are not identifiable using conventional amplitude-only information.

Light scattering methods for tissue diagnosis

Light scattering has become a common biomedical research tool, enabling diagnostic sensitivity to myriad tissue alterations associated with disease. Light-tissue interactions are particularly attractive for diagnostics due to the variety of contrast mechanisms that can be used, including spectral, angle-resolved, and Fourier-domain detection. Photonic diagnostic tools offer further benefit in that they are non-ionizing, non-invasive, and give real-time feedback. In this review, we summarize recent innovations in light scattering technologies, with a focus on clinical achievements over the previous ten years.

Angular range, sampling and noise considerations for inverse light scattering analysis of nuclear morphology

In recent years, significant work has been devoted to the use of angle-resolved elastic scattering for the extraction of nuclear morphology in tissue. By treating the nucleus as a Mie scattering object, techniques such as angle-resolved low-coherence interferometry (a/LCI) have demonstrated substantial success in identifying nuclear alterations associated with dysplasia. Because optical biopsies are inherently noninvasive, only a small, discretized portion of the 4π scattering field can be collected from tissue, limiting the amount of information available for diagnostic purposes. In this work, we comprehensively characterize the diagnostic impact of variations in angular sampling, range and noise for inverse light scattering analysis of nuclear morphology, using a previously reported dataset from 40 patients undergoing a/LCI optical biopsy for cervical dysplasia. The results from this analysis are applied to a benchtop scanning a/LCI system which compromises angular range for wide-area scanning capability. This work will inform the design of next-generation optical biopsy probes by directing optical design towards parameters which offer the most diagnostic utility.

Fiber-based visible and near infrared optical coherence tomography (vnOCT) enables quantitative elastic light scattering spectroscopy in human retina

Elastic light scattering spectroscopy (ELSS) has been proven a powerful method in measuring tissue structures with exquisite nanoscale sensitivity. However, ELSS contrast in the living human retina has been relatively underexplored, primarily due to the lack of imaging tools with a large spectral bandwidth. Here, we report a simple all fiber-based setup to implement dual-channel visible and near infrared (NIR) optical coherence tomography (vnOCT) for human retinal imaging, bridging over a 300nm spectral gap. Remarkably, the fiber components in our vnOCT system support single-mode propagation for both visible and NIR light, both of which maintain excellent interference efficiencies with fringe visibility of 97% and 90%, respectively. The longitudinal chromatic aberration from the eye is corrected by a custom-designed achromatizing lens. The elegant fiber-based design enables simultaneous imaging for both channels and allows comprehensive ELSS analysis on several important anatomical layers, including nerve fiber layer, outer segment of the photoreceptors and retinal pigment epithelium. This vnOCT platform and method of ELSS analysis open new opportunities in understanding structure-function relationship in the human retina and in exploring new biomarkers for retinal diseases.

Emerging optical methods for endoscopic surveillance of Barrett's oesophagus

Barrett's oesophagus is an acquired metaplastic condition that predisposes patients to the development of oesophageal adenocarcinoma, prompting the use of surveillance regimes to detect early malignancy for endoscopic therapy with curative intent. The currently accepted surveillance regime uses white light endoscopy together with random biopsies, but has poor sensitivity and discards information from numerous light-tissue interactions that could be exploited to probe structural, functional, and molecular changes in the tissue. Advanced optical methods are now emerging that are highly sensitive to these changes and hold potential to improve surveillance of Barrett's oesophagus if they can be applied endoscopically. The next decade will see some of these exciting new methods applied to surveillance of Barrett's oesophagus in new device architectures for the first time, potentially leading to a long-awaited improvement in the standard of care.

Is the nuclear refractive index lower than cytoplasm? Validation of phase measurements and implications for light scattering technologies

The refractive index (RI) of biological materials is a fundamental parameter for the optical characterization of living systems. Numerous light scattering technologies are grounded in a quantitative knowledge of the refractive index at cellular and subcellular scales. Recent work in quantitative phase microscopy (QPM) has called into question the widely held assumption that the index of the cell nucleus is greater than that of the cytoplasm, a result which disagrees with much of the current literature. In this work, we critically examine the measurement of the nuclear and whole-cell refractive index using QPM, validating that nuclear refractive index is lower than that of cytoplasm in four diverse cell lines and their corresponding isolated nuclei. We further examine Mie scattering and phase-wrapping as potential sources of error in these measurements, finding they have minimal impact. Finally, we use simulation to examine the effects of incorrect RI assumptions on nuclear morphology measurements using angle-resolved scattering information. Despite an erroneous assumption of the nuclear refractive index, accurate measurement of nuclear morphology was maintained, suggesting that light scattering modalities remain effective.

Feasibility of clinical detection of cervical dysplasia using angle-resolved low coherence interferometry measurements of depth-resolved nuclear morphology

This study sought to establish the feasibility of using in situ depth-resolved nuclear morphology measurements for detection of cervical dysplasia. Forty enrolled patients received routine cervical colposcopy with angle-resolved low coherence interferometry (a/LCI) measurements of nuclear morphology. a/LCI scans from 63 tissue sites were compared to histopathological analysis of co-registered biopsy specimens which were classified as benign, low-grade squamous intraepithelial lesion (LSIL), or high-grade squamous intraepithelial lesion (HSIL). Results were dichotomized as dysplastic (LSIL/HSIL) versus non-dysplastic and HSIL versus LSIL/benign to determine both accuracy and potential clinical utility of a/LCI nuclear morphology measurements. Analysis of a/LCI data was conducted using both traditional Mie theory based processing and a new hybrid algorithm that provides improved processing speed to ascertain the feasibility of real-time measurements. Analysis of depth-resolved nuclear morphology data revealed a/LCI was able to detect a significant increase in the nuclear diameter at the depth bin containing the basal layer of the epithelium for dysplastic versus non-dysplastic and HSIL versus LSIL/Benign biopsy sites (both p < 0.001). Both processing techniques resulted in high sensitivity and specificity (>0.80) in identifying dysplastic biopsies and HSIL. The hybrid algorithm demonstrated a threefold decrease in processing time at a slight cost in classification accuracy. The results demonstrate the feasibility of using a/LCI as an adjunctive clinical tool for detecting cervical dysplasia and guiding the identification of optimal biopsy sites. The faster speed from the hybrid algorithm offers a promising approach for real-time clinical analysis.

Toward real-time quantification of fluorescence molecular probes using target/background ratio for guiding biopsy and endoscopic therapy of esophageal neoplasia

Multimodal endoscopy using fluorescence molecular probes is a promising method of surveying the entire esophagus to detect cancer progression. Using the fluorescence ratio of a target compared to a surrounding background, a quantitative value is diagnostic for progression from Barrett's esophagus to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). However, current quantification of fluorescent images is done only after the endoscopic procedure. We developed a Chan-Vese-based algorithm to segment fluorescence targets, and subsequent morphological operations to generate background, thus calculating target/background (T/B) ratios, potentially to provide real-time guidance for biopsy and endoscopic therapy. With an initial processing speed of 2 fps and by calculating the T/B ratio for each frame, our method provides quasireal-time quantification of the molecular probe labeling to the endoscopist. Furthermore, an automatic computer-aided diagnosis algorithm can be applied to the recorded endoscopic video, and the overall T/B ratio is calculated for each patient. The receiver operating characteristic curve was employed to determine the threshold for classification of HGD/EAC using leave-one-out cross-validation. With 92% sensitivity and 75% specificity to classify HGD/EAC, our automatic algorithm shows promising results for a surveillance procedure to help manage esophageal cancer and other cancers inspected by endoscopy.

Light scattering spectroscopy identifies the malignant potential of pancreatic cysts during endoscopy

Pancreatic cancers are usually detected at an advanced stage and have poor prognosis. About one fifth of these arise from pancreatic cystic lesions. Yet not all lesions are precancerous, and imaging tools lack adequate accuracy for distinguishing precancerous from benign cysts. Therefore, decisions on surgical resection usually rely on endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Unfortunately, cyst fluid often contains few cells, and fluid chemical analysis lacks accuracy, resulting in dire consequences, including unnecessary pancreatic surgery for benign cysts and the development of cancer. Here, we report an optical spectroscopic technique, based on a spatial gating fibre-optic probe, that predicts the malignant potential of pancreatic cystic lesions during routine diagnostic EUS-FNA procedures. In a double-blind prospective study in 25 patients, with 14 cysts measured in vivo and 13 postoperatively, the technique achieved an overall accuracy of 95%, with a 95%confidence interval of 78-99%, in cysts with definitive diagnosis.

Analyzing spatial correlations in tissue using angle-resolved low coherence interferometry measurements guided by co-located optical coherence tomography

Angle-resolved low coherence interferometry (a/LCI) is an optical technique used to measure nuclear morphology in situ. However, a/LCI is not an imaging modality and can produce ambiguous results when the measurements are not properly oriented to the tissue architecture. Here we present a 2D a/LCI system which incorporates optical coherence tomography imaging to guide the measurements. System design and characterization are presented, along with example cases which demonstrate the utility of the combined measurements. In addition, future development and applications of this dual modality approach are discussed.

Biophotonic endoscopy: a review of clinical research techniques for optical imaging and sensing of early gastrointestinal cancer

Detection, characterization, and staging constitute the fundamental elements in the endoscopic diagnosis of gastrointestinal diseases, but histology still remains the diagnostic gold standard. New developments in endoscopic techniques may challenge histopathology in the near future. An ideal endoscopic technique should combine a wide-field, "red flag" screening technique with an optical contrast or microscopy method for characterization and staging, all simultaneously available during the procedure. In theory, biophotonic advances have the potential to unite these elements to allow in vivo "optical biopsy." These techniques may ultimately offer the potential to increase the rates of detection of high risk lesions and the ability to target biopsies and resections, and so reduce the need for biopsy, costs, and uncertainty for patients. However, their utility and sensitivity in clinical practice must be evaluated against those of conventional histopathology. This review describes some of the most recent applications of biophotonics in endoscopic optical imaging and metrology, along with their fundamental principles and the clinical experience that has been acquired in their deployment as tools for the endoscopist. Particular emphasis has been placed on translational label-free optical techniques, such as fluorescence spectroscopy, fluorescence lifetime imaging microscopy (FLIM), two-photon and multi-photon microscopy, second harmonic generation (SHG) and third harmonic generation (THG) imaging, optical coherence tomography (OCT), diffuse reflectance, Raman spectroscopy, and molecular imaging.

Evaluation of hybrid algorithm for analysis of scattered light using ex vivo nuclear morphology measurements of cervical epithelium

We evaluate a new hybrid algorithm for determining nuclear morphology using angle-resolved low coherence interferometry (a/LCI) measurements in ex vivo cervical tissue. The algorithm combines Mie theory based and continuous wavelet transform inverse light scattering analysis. The hybrid algorithm was validated and compared to traditional Mie theory based analysis using an ex vivo tissue data set. The hybrid algorithm achieved 100% agreement with pathology in distinguishing dysplastic and non-dysplastic biopsy sites in the pilot study. Significantly, the new algorithm performed over four times faster than traditional Mie theory based analysis.

Three-dimensional photoacoustic endoscopic imaging of the rabbit esophagus

We report photoacoustic and ultrasonic endoscopic images of two intact rabbit esophagi. To investigate the esophageal lumen structure and microvasculature, we performed in vivo and ex vivo imaging studies using a 3.8-mm diameter photoacoustic endoscope and correlated the images with histology. Several interesting anatomic structures were newly found in both the in vivo and ex vivo images, which demonstrates the potential clinical utility of this endoscopic imaging modality. In the ex vivo imaging experiment, we acquired high-resolution motion-artifact-free three-dimensional photoacoustic images of the vasculatures distributed in the walls of the esophagi and extending to the neighboring mediastinal regions. Blood vessels with apparent diameters as small as 190 μm were resolved. Moreover, by taking advantage of the dual-mode high-resolution photoacoustic and ultrasound endoscopy, we could better identify and characterize the anatomic structures of the esophageal lumen, such as the mucosal and submucosal layers in the esophageal wall, and an esophageal branch of the thoracic aorta. In this paper, we present the first photoacoustic images showing the vasculature of a vertebrate esophagus and discuss the potential clinical applications and future development of photoacoustic endoscopy.

Current concepts and future of noninvasive procedures for diagnosing oral squamous cell carcinoma--a systematic review

Background

Oral squamous cell carcinoma (OSCC) has a remarkably high incidence worldwide, and a fairly serious prognosis, encouraging further research into advanced technologies for noninvasive methods of making early diagnoses, ideally in primary care settings.

Objectives

Our purpose was to examine the validity of using advanced noninvasive technologies in diagnosis of OSCC by identifying and evaluating relevant published reports.

Data source

MEDLINE, EMBASE, and CINAHL were searched to identify clinical trials and other information published between 1990 and 10 June 2014; the searches of MEDLINE and EMBASE were updated to November 2014. Study selection: Studies of noninvasive methods of diagnosing OSCC, including oral brush biopsy, optical biopsy, saliva-based oral cancer diagnosis, and others were included.

Data extraction

Data were abstracted and evaluated in duplicate for possible relevance on two occasions at an interval of 2 months before being included or excluded.

Data synthesis

This study identified 163 studies of noninvasive methods for diagnosing OSCC that met the inclusion criteria. These included six studies of oral brush biopsy, 42 of saliva-based oral diagnosis, and 115 of optical biopsy. Sixty nine of these studies were assessed by the modified version of the QUADAS instrument. Saliva-based oral cancer diagnosis and optical biopsy were found to be promising noninvasive methods for diagnosing OSCC.

Limitation

The strength of evidence was rated low for accuracy outcomes because the studies did not report important details required to assess the risk for bias.

Conclusions

It is clear that screening for and early detection of cancer and pre-cancerous lesions have the potential to reduce the morbidity and mortality of this disease. Advances in technologies for saliva-based oral diagnosis and optical biopsy are promising pathways for the future development of more effective noninvasive methods for diagnosing OSCC that are easy to perform clinically in primary care settings.

Three-dimensional photoacoustic endoscopic imaging of the rabbit esophagus

We report photoacoustic and ultrasonic endoscopic images of two intact rabbit esophagi. To investigate the esophageal lumen structure and microvasculature, we performed in vivo and ex vivo imaging studies using a 3.8-mm diameter photoacoustic endoscope and correlated the images with histology. Several interesting anatomic structures were newly found in both the in vivo and ex vivo images, which demonstrates the potential clinical utility of this endoscopic imaging modality. In the ex vivo imaging experiment, we acquired high-resolution motion-artifact-free three-dimensional photoacoustic images of the vasculatures distributed in the walls of the esophagi and extending to the neighboring mediastinal regions. Blood vessels with apparent diameters as small as 190 μm were resolved. Moreover, by taking advantage of the dual-mode high-resolution photoacoustic and ultrasound endoscopy, we could better identify and characterize the anatomic structures of the esophageal lumen, such as the mucosal and submucosal layers in the esophageal wall, and an esophageal branch of the thoracic aorta. In this paper, we present the first photoacoustic images showing the vasculature of a vertebrate esophagus and discuss the potential clinical applications and future development of photoacoustic endoscopy.

Molecular markers and imaging tools to identify malignant potential in Barrett's esophagus

Due to its rapidly rising incidence and high mortality, esophageal adenocarcinoma is a major public health concern, particularly in Western countries. The steps involved in the progression from its predisposing condition, gastroesophageal reflux disease, to its premalignant disorder, Barrett’s esophagus, and to cancer, are incompletely understood. Current screening and surveillance methods are limited by the lack of population-wide utility, incomplete sampling of standard biopsies, and subjectivity of evaluation. Advances in endoscopic ablation have raised the hope of effective therapy for eradication of high-risk Barrett’s lesions, but improvements are needed in determining when to apply this treatment and how to follow patients clinically. Researchers have evaluated numerous potential molecular biomarkers with the goal of detecting dysplasia, with varying degrees of success. The combination of biomarker panels with epidemiologic risk factors to yield clinical risk scoring systems is promising. New approaches to sample tissue may also be combined with these biomarkers for less invasive screening and surveillance. The development of novel endoscopic imaging tools in recent years has the potential to markedly improve detection of small foci of dysplasia in vivo. Current and future efforts will aim to determine the combination of markers and imaging modalities that will most effectively improve the rate of early detection of high-risk lesions in Barrett’s esophagus.

Wavelet transform fast inverse light scattering analysis for size determination of spherical scatterers

We present a fast approach for size determination of spherical scatterers using the continuous wavelet transform of the angular light scattering profile to address the computational limitations of previously developed sizing techniques. The potential accuracy, speed, and robustness of the algorithm were determined in simulated models of scattering by polystyrene beads and cells. The algorithm was tested experimentally on angular light scattering data from polystyrene bead phantoms and MCF-7 breast cancer cells using a 2D a/LCI system. Theoretical sizing of simulated profiles of beads and cells produced strong fits between calculated and actual size (r(2) = 0.9969 and r(2) = 0.9979 respectively), and experimental size determinations were accurate to within one micron.

Endoscopic Optical Coherence Tomography for Clinical Gastroenterology

Optical coherence tomography (OCT) is a real-time optical imaging technique that is similar in principle to ultrasonography, but employs light instead of sound waves and allows depth-resolved images with near-microscopic resolution. Endoscopic OCT allows the evaluation of broad-field and subsurface areas and can be used ancillary to standard endoscopy, narrow band imaging, chromoendoscopy, magnification endoscopy, and confocal endomicroscopy. This review article will provide an overview of the clinical utility of endoscopic OCT in the gastrointestinal tract and of recent achievements using state-of-the-art endoscopic 3D-OCT imaging systems.

Numerical investigation of two-dimensional light scattering patterns of cervical cell nuclei to map dysplastic changes at different epithelial depths

We use an extensive set of quantitative histopathology data to construct realistic three-dimensional models of normal and dysplastic cervical cell nuclei at different epithelial depths. We then employ the finite-difference time-domain method to numerically simulate the light scattering response of these representative models as a function of the polar and azimuthal scattering angles. The results indicate that intensity and shape metrics computed from two-dimensional scattering patterns can be used to distinguish between different diagnostic categories. Our numerical study also suggests that different epithelial layers and angular ranges need to be considered separately to fully exploit the diagnostic potential of two-dimensional light scattering measurements.

Targeted imaging of esophageal neoplasia with a fluorescently labeled peptide: first-in-human results

Esophageal adenocarcinoma is rising rapidly in incidence and usually develops from Barrett's esophagus, a precursor condition commonly found in patients with chronic acid reflux. Premalignant lesions are challenging to detect on conventional screening endoscopy because of their flat appearance. Molecular changes can be used to improve detection of early neoplasia. We have developed a peptide that binds specifically to high-grade dysplasia and adenocarcinoma. We first applied the peptide ex vivo to esophageal specimens from 17 patients to validate specific binding. Next, we performed confocal endomicroscopy in vivo in 25 human subjects after topical peptide administration and found 3.8-fold greater fluorescence intensity for esophageal neoplasia compared with Barrett's esophagus and squamous epithelium with 75% sensitivity and 97% specificity. No toxicity was attributed to the peptide in either animal or patient studies. Therefore, our first-in-human results show that this targeted imaging agent is safe and may be useful for guiding tissue biopsy and for early detection of esophageal neoplasia and potentially other cancers of epithelial origin, such as bladder, colon, lung, pancreas, and stomach.

Advances in optical adjunctive AIDS for visualisation and detection of oral malignant and potentially malignant lesions

Traditional methods of screening for oral potentially malignant disorders and oral malignancies involve a conventional oral examination with digital palpation. Evidence indicates that conventional examination is a poor discriminator of oral mucosal lesions. A number of optical aids have been developed to assist the clinician to detect oral mucosal abnormalities and to differentiate benign lesions from sinister pathology. This paper discusses advances in optical technologies designed for the detection of oral mucosal abnormalities. The literature regarding such devices, VELscope and Identafi, is critically analysed, and the novel use of Narrow Band Imaging within the oral cavity is also discussed. Optical aids are effective in assisting with the detection of oral mucosal abnormalities; however, further research is required to evaluate the usefulness of these devices in differentiating benign lesions from potentially malignant and malignant lesions.

A scattering phantom for observing long range order with two-dimensional angle-resolved Low-Coherence Interferometry

Angle-resolved low coherence interferometry (a/LCI) is an approach for assessing tissue structure based on light scattering data. Recent advances in a/LCI have extended the analysis to study scattering distributions in two dimensions. In order to provide suitable scattering phantoms for 2D a/LCI, we have developed phantoms based on soft lithography which can provide a range of structures including long range order. Here we characterize these phantoms and demonstrate their utility for providing standardized multi-scale structural information for light scattering measurements.

Subsquamous intestinal metaplasia after ablation of Barrett's esophagus: frequency and importance

PURPOSE OF REVIEW

This article reviews reports on the prevalence of subsquamous intestinal metaplasia (SSIM) in patients with Barrett's esophagus, and the implications of SSIM in the neoplastic progression of Barrett's esophagus to esophageal adenocarcinoma.

RECENT FINDINGS

Endoscopic eradication therapy for dysplastic Barrett's esophagus has become an encouraging alternative to esophagectomy or continued endoscopic surveillance. However, the presence of SSIM before and after ablation is concerning because this tissue may have potential for malignant progression, is not visible by conventional endoscopy, and may evade detection by random esophageal biopsy sampling methods. Advances in endoscopic high-resolution three-dimensional optical coherence tomography recently have revealed SSIM in a majority of patients both before and after complete eradication of Barrett's esophagus by radiofrequency ablation. Studies suggest that although cells of Barrett's glands are highly proliferative, the cells of these buried glands are more dormant. Nevertheless, the malignant potential of SSIM cells remains undetermined.

SUMMARY

Novel endoscopic imaging demonstrates that SSIM is present in the majority of patients with Barrett's esophagus, both before and after ablative therapy. Although these subsquamous cells exhibit less proliferative activity than those of typical surface Barrett's glands, the malignant potential of the buried glands, especially when challenged by injurious factors, remains largely unknown. Future methods to detect subsurface dysplasia will be needed.

Optical molecular imaging in the gastrointestinal tract

Recent developments in optical molecular imaging allow for real-time identification of morphologic and biochemical changes in tissue associated with gastrointestinal neoplasia. This review summarizes widefield and high-resolution imaging modalities in preclinical and clinical evaluation for the detection of colorectal cancer and esophageal cancer. Widefield techniques discussed include high-definition white light endoscopy, narrow band imaging, autofluoresence imaging, and chromoendoscopy; high-resolution techniques discussed include probe-based confocal laser endomicroscopy, high-resolution microendoscopy, and optical coherence tomography. New approaches to enhance image contrast using vital dyes and molecular-specific targeted contrast agents are evaluated.

Algorithm for automated selection of application-specific fiber-optic reflectance probes

Several optical techniques and fiber-optic probe systems have been designed to measure the optical properties of tissue. While a wide range of options is often beneficial, it poses a problem to investigators selecting which method to use for their biomedical application of interest. We present a methodology to optimally select a probe that matches the application requirements. Our method is based both on matching a probe's mean sampling depth with the optimal diagnostic depth of the clinical application and on choosing a probe whose interrogation depth and path length is the least sensitive to alterations in the target medium's optical properties. Satisfying these requirements ensures that the selected probe consistently assesses the relevant tissue volume with minimum variability. To aid in probe selection, we have developed a publicly available graphical user interface that takes the desired sampling depth and optical properties of the medium as its inputs and automatically ranks different techniques in their ability to robustly target the desired depth. Techniques investigated include single fiber spectroscopy, differential path length spectroscopy, polarization-gating, elastic light scattering spectroscopy, and diffuse reflectance. The software has been applied to biological case studies.

A 2.5-mm diameter probe for photoacoustic and ultrasonic endoscopy

We have created a 2.5-mm outer diameter integrated photo-acoustic and ultrasonic mini-probe which can be inserted into a standard video endoscope's instrument channel. A small-diameter focused ultrasonic transducer made of PMN-PT provides adequate signal sensitivity, and enables miniaturization of the probe. Additionally, this new endoscopic probe utilizes the same scanning mirror and micromotor-based built-in actuator described in our previous reports; however, the length of the rigid distal section of the new probe has been further reduced to ~35 mm. This paper describes the technical details of the mini-probe and presents experimental results that both quantify the imaging performance and demonstrate its in vivo imaging capability, which suggests that it could work as a mini-probe for certain clinical applications.

Nanometer-scale sizing accuracy of particle suspensions on an unmodified cell phone using elastic light scattering

We report on the construction of a Fourier plane imaging system attached to a cell phone. By illuminating particle suspensions with a collimated beam from an inexpensive diode laser, angularly resolved scattering patterns are imaged by the phone's camera. Analyzing these patterns with Mie theory results in predictions of size distributions of the particles in suspension. Despite using consumer grade electronics, we extracted size distributions of sphere suspensions with better than 20 nm accuracy in determining the mean size. We also show results from milk, yeast, and blood cells. Performing these measurements on a portable device presents opportunities for field-testing of food quality, process monitoring, and medical diagnosis.

Optical endomicroscopy and the road to real-time, in vivo pathology: present and future

Epithelial cancers account for substantial mortality and are an important public health concern. With the need for earlier detection and treatment of these malignancies, the ability to accurately detect precancerous lesions has an increasingly important role in controlling cancer incidence and mortality. New optical technologies are capable of identifying early pathology in tissues or organs in which cancer is known to develop through stages of dysplasia, including the esophagus, colon, pancreas, liver, bladder, and cervix. These diagnostic imaging advances, together as a field known as optical endomicroscopy, are based on confocal microscopy, spectroscopy-based imaging, and optical coherence tomography (OCT), and function as "optical biopsies," enabling tissue pathology to be imaged in situ and in real time without the need to excise and process specimens as in conventional biopsy and histopathology. Optical biopsy techniques can acquire high-resolution, cross-sectional images of tissue structure on the micron scale through the use of endoscopes, catheters, laparoscopes, and needles. Since the inception of these technologies, dramatic technological advances in accuracy, speed, and functionality have been realized. The current paradigm of optical biopsy, or single-area, point-based images, is slowly shifting to more comprehensive microscopy of larger tracts of mucosa. With the development of Fourier-domain OCT, also known as optical frequency domain imaging or, more recently, volumetric laser endomicroscopy, comprehensive surveillance of the entire distal esophagus is now achievable at speeds that were not possible with conventional OCT technologies. Optical diagnostic technologies are emerging as clinically useful tools with the potential to set a new standard for real-time diagnosis. New imaging techniques enable visualization of high-resolution, cross-sectional images and offer the opportunity to guide biopsy, allowing maximal diagnostic yields and appropriate staging without the limitations and risks inherent with current random biopsy protocols. However, the ability of these techniques to achieve widespread adoption in clinical practice depends on future research designed to improve accuracy and allow real-time data transmission and storage, thereby linking pathology to the treating physician. These imaging advances are expected to eventually offer a see-and-treat paradigm, leading to improved patient care and potential cost reduction.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/5372548637202968.

Simultaneous functional photoacoustic and ultrasonic endoscopy of internal organs in vivo

At present, clinicians routinely apply ultrasound endoscopy in a variety of interventional procedures that provide treatment solutions for diseased organs. Ultrasound endoscopy not only produces high-resolution images, but also is safe for clinical use and broadly applicable. However, for soft tissue imaging, its mechanical wave-based image contrast fundamentally limits its ability to provide physiologically specific functional information. By contrast, photoacoustic endoscopy possesses a unique combination of functional optical contrast and high spatial resolution at clinically relevant depths, ideal for imaging soft tissues. With these attributes, photoacoustic endoscopy can overcome the current limitations of ultrasound endoscopy. Moreover, the benefits of photoacoustic imaging do not come at the expense of existing ultrasound functions; photoacoustic endoscopy systems are inherently compatible with ultrasound imaging, thereby enabling multimodality imaging with complementary contrast. Here we present simultaneous photoacoustic and ultrasonic dual-mode endoscopy and show its ability to image internal organs in vivo, thus illustrating its potential clinical application.

Monte Carlo model of the penetration depth for polarization gating spectroscopy: influence of illumination-collection geometry and sample optical properties

Polarization-gating has been widely used to probe superficial tissue structures, but the penetration depth properties of this method have not been completely elucidated. This study employs a polarization-sensitive Monte Carlo method to characterize the penetration depth statistics of polarization-gating. The analysis demonstrates that the penetration depth depends on both the illumination-collection geometry [illumination-collection area (R) and collection angle (θ(c))] and on the optical properties of the sample, which include the scattering coefficient (μ(s)), absorption coefficient (μ(a)), anisotropy factor (g), and the type of the phase function. We develop a mathematical expression relating the average penetration depth to the illumination-collection beam properties and optical properties of the medium. Finally, we quantify the sensitivity of the average penetration depth to changes in optical properties for different geometries of illumination and collection. The penetration depth model derived in this study can be applied to optimizing application-specific fiber-optic probes to target a sampling depth of interest with minimal sensitivity to the optical properties of the sample.

Spectral Imaging with Scattered Light: From Early Cancer Detection to Cell Biology

This article reports the evolution of scanning spectral imaging techniques using scattered light for minimally invasive detection of early cancerous changes in tissue and cell biology applications. Optical spectroscopic techniques have shown promising results in the diagnosis of disease on a cellular scale. They do not require tissue removal, can be performed in vivo, and allow for real time diagnoses. Fluorescence and Raman spectroscopy are most effective in revealing molecular properties of tissue. Light scattering spectroscopy (LSS) relates the spectroscopic properties of light elastically scattered by small particles, such as epithelial cell nuclei and organelles, to their size, shape and refractive index. It is capable of characterizing the structural properties of tissue on cellular and sub-cellular scales. However, in order to be useful in the detection of early cancerous changes which are otherwise not visible to the naked eye, it must rapidly survey a comparatively large area while simultaneously detecting these cellular changes. Both goals are achieved by combining LSS with spatial scanning imaging. Two examples are described in this article. The first reviews a clinical system for screening patients with Barrett's esophagus. The second presents a novel advancement in confocal light absorption and scattering spectroscopic (CLASS) microscopy.

Angle-resolved low-coherence interferometry: an optical biopsy technique for clinical detection of dysplasia in Barrett's esophagus

Angle-resolved low-coherence interferometry (a/LCI) is an optical biopsy technique that measures scattered light from tissue to determine nuclear size with submicron-level accuracy. The a/LCI probe can be deployed through the accessory channel of a standard endoscope and provides feedback to physicians to guide physical biopsies. The technique has been validated in animal and ex vivo human studies, and has been used to detect dysplasia in Barrett's esophagus patients in vivo. In a recent clinical study of 46 Barrett's esophagus patients, a/LCI was able to detect dysplasia with 100% sensitivity and 84% specificity. This report reviews the technique and discusses its potential clinical utility.

A case of therapy-related myeloid neoplasm in a patient with Crohn's disease treated with azathioprine

Acute leukaemia (AL) has been observed in association with Crohn's disease (CD) notably in patients treated with azathioprine (AZA), which is an immunosuppressant known for its carcinogenicity and in particular known to induce therapy-related acute myeloid leukaemia according to the 2008 WHO classification. Whereas the link between inflammatory bowel disease and AL has been well established, the exact role of AZA remains controversial. In this paper, we report the case of a 71-year-old white Caucasian male with CD treated for 7 years with AZA who developed an acute leukaemia. Chemotherapy was administered unsuccessfully and the patient died from this haematological disorder 9 months after diagnosis. We reviewed the current evidence on the interactions between CD, AL and AZA as well as the potential underlying mechanisms of leukaemia in AZA-treated patients. From this review, we concluded that AL should be questioned when facing cytopenia in a patient with CD. The nature of the association between AZA and AL in CD patients warrants further investigation.

Detection of intestinal dysplasia using angle-resolved low coherence interferometry

Angle-resolved low coherence interferometry (a/LCI) is an optical biopsy technique that allows for depth-resolved, label-free measurement of the average size and optical density of cell nuclei in epithelial tissue to assess the tissue health. a/LCI has previously been used clinically to identify the presence of dysplasia in Barrett's Esophagus patients undergoing routine surveillance. We present the results of a pilot, ex vivo study of tissues from 27 patients undergoing partial colonic resection surgery, conducted to evaluate the ability of a/LCI to identify dysplasia. Performance was determined by comparing the nuclear morphology measurements with pathological assessment of co-located physical biopsies. A statistically significant correlation between increased average nuclear size, reduced nuclear density, and the presence of dysplasia was noted at the basal layer of the epithelium, at a depth of 200 to 300 μm beneath the tissue surface. Using a decision line determined from a receiver operating characteristic, a/LCI was able to separate dysplastic from healthy tissues with a sensitivity of 92.9% (13/14), a specificity of 83.6% (56/67), and an overall accuracy of 85.2% (69/81). The study illustrates the extension of the a/LCI technique to the detection of intestinal dysplasia, and demonstrates the need for future in vivo studies.

Development of angle-resolved low coherence interferometry for clinical detection of dysplasia

This review covers the development of angle-resolved low coherence interferometry (a/LCI) from initial development through clinical application. In the first applications, the approach used a time-domain interferometry scheme and was validated using animal models of carcinogenesis to assess the feasibility of detecting dysplasia in situ. Further development of the approach led to Fourier-domain interferometry schemes with higher throughput and endoscope-compatible probes to enable clinical application. These later implementations have been applied to clinical studies of dysplasia in Barrett's esophagus tissues, a metaplastic tissue type that is associated with an increased risk of esophageal adenocarcinoma. As an alternative to systematic biopsy, the a/LCI approach offers high sensitivity and specificity for detecting dysplasia in these tissues while avoiding the need for tissue removal or exogenous contrast agents. Here, the various implementations of a/LCI are discussed and the results of the preliminary animal experiments and ex vivo human tissue studies are reviewed. A review of a recent in vivo clinical study is also presented.